Global & Disaster Medicine

Archive for September, 2017

Dear Friend,
The devastation from Hurricane Maria is truly heartbreaking in its impact on millions of people. We know this is a challenging and emotional time, and the American Red Cross is working around the clock to get help to those who need it most. Maria was the most intense hurricane to hit Puerto Rico in more than 80 years. Striking just days after Hurricane Irma had thrashed the U.S. Virgin Islands, Maria carved a severe trail of destruction across Puerto Rico and the U.S. Virgin Islands again, devastating homes, businesses, infrastructure and crops; knocking out power and cell phone service; and spurring widespread flooding and mudslides.

Impacted communities in these two U.S. territories need critical relief like clean water, food, hygiene items and cleanup kits as they work to return to a normal life.

The Red Cross has mobilized hundreds of its disaster workers and relief supplies to support our response efforts in the islands. As of September 29, this includes:

On 23 August 2017, a 31-year-old male from Tamatave, visiting Ankazobe District in central highlands, developed malaria-like symptoms. On 27 August, he developed respiratory symptoms during his journey in a shared public taxi from Ankazobe District to Tamatave (via Antananarivo). His condition worsened and he died. His body was prepared for a funeral at the nearest hospital, Moramanga District Hospital, without safety procedures. Additionally, 31 people who came into contact with this case either through direct contact with the primary case or had other epidemiological links, became ill, and four cases of them died.

The outbreak was detected on 11 September, following the death of a 47-year-old woman from Antananarivo, who was admitted to a hospital with respiratory failure caused by pneumonic plague. The public health authorities Direction de la Veille Sanitaire et de la Surveillance Epidémiologique (DVSSE) immediately launched field investigations.

As of 28 September 2017, a total of 51 cases (suspected, probable and confirmed) of pneumonic plague, including 12 deaths were reported in the country. The diagnosis was confirmed by the Institut Pasteur de Madagascar by polymerase chain reaction test and using rapid diagnostic test.

In addition to the 51 suspected, probable and confirmed cases of pneumonic plague, and during the same period another 53 cases of bubonic plague including seven deaths have been reported throughout the country. One case of septicaemic plague has also been identified and they were not directly linked to the outbreak.

Public health response

The Ministry of Health activated crisis units in Antananarivo and Toamasina and all cases have been provided access to treatment at no cost. Active case finding and contact tracing are on-going and all pneumonic cases are being isolated and treated, and all contacts are receiving chemoprophylaxis.

There are additional ongoing key public health response measures which include:

Ongoing investigation of new cases.

Strengthening of the epidemiological surveillance in the affected and surrounding districts, including contact identification, administration of chemoprophylaxis, and monitoring close contacts of pneumonic plague cases.

Disinsection of affected areas, including rodent and vector control.

Raising awareness of the population about prevention and actions after exposure.

Raising awareness among health care workers and providing information including infection control measures, and implementation of safe burial practices.

WHO risk assessment

Plague is an infectious disease caused by the bacteria Yersinia pestis, a zoonotic bacteria, usually found in small mammals and their fleas. It is transmitted between animals from their fleas. Humans can be contaminated by the bite of infected fleas, through direct contact with infected materials or by inhalation.

There are three forms of plague infection, depending on the route of infection: bubonic, septicaemic and pneumonic.

Bubonic plague (known in mediaeval Europe as the ‘Black Death’) is the most common form of plague and is caused by the bite of an infected flea. Plague bacillus, Yersinia pestis, enters at the bite and travels through the lymphatic system to the nearest lymph node where it replicates itself. The lymph node then becomes inflamed, tense and painful, and is called a “bubo”. At advanced stages of the infection the inflamed lymph nodes can turn into open sores filled with puss.

Pneumonic plague-or lung-based plague- is the most virulent form of plague. Incubation period can be as short as 24 hours. Typically, the pneumonic form is caused by spread to the lungs from advanced bubonic plague. However, a person with secondary pneumonic plague may form aerosolized infective droplets and transmit plague via droplets to other humans. Untreated pneumonic plague is always fatal.

Septicaemic plague occurs when infection spreads through the bloodstream, following a bubonic or a pneumonic plague.

Plague can be a very severe disease in people, particularly in its septicaemic and pneumonic forms, with a case-fatality ratio of 30–100% if left untreated. The pneumonic form is invariably fatal unless treated early, is especially contagious and can trigger severe epidemics through person-to-person contact via droplets in the air.

Plague is an endemic disease in Madagascar; cases of bubonic plague are reported nearly every year, during the epidemic season (between September and April). However, the ongoing pneumonic plague event has been reported in a non-endemic area and in densely populated coastal cities for the first time.

Pneumonic plague is a form of plague that is transmissible from person-to-person, with a potential to trigger severe epidemics if inadequately controlled. Detection of this outbreak occurred more than two weeks after the first case died during which cases travelled to different parts of the country, including the capital Antananarivo. Therefore, the overall risk at the national level is high. The overall regional risk is moderate due to frequent flights to neighboring Indian Ocean islands. The global risk is low.

WHO advice

Prevention and control measures

Preventive measures include informing people when zoonotic plague is present in their environment and advising them to take precautions against flea bites and not to handle animal carcasses. The most rapid and effective method for controlling fleas is to apply an appropriate insecticide formulated as a dust or low-volume spray. People, especially health workers, should also avoid direct contact with infected tissues such as buboes, or close exposure to patients with pneumonic plague. Important prevention and control measures include:

Find and stop the source of infection.

Protect health workers: inform and train them on infection prevention and control.

Isolate: patients with pneumonic plague. They should be isolated so as not to infect others via air droplets.

Surveillance: identify and monitor close contacts of pneumonic plague patients and give them a seven day chemoprophylaxis.

Obtain specimens which should be carefully collected and sent to labs for testing.

Ensure safe burial practices.

Treatment

Untreated plague can be rapidly fatal, so early diagnosis and treatment is essential for survival and reduction of complications. Antibiotics and supportive therapy are effective against plague if patients are diagnosed in time.

Travel advice

WHO advises against any restriction on travel or trade on Madagascar based on the available information. It is recommended to provide information at the ports of entry (airports, seaports) of Madagascar about the disease and the necessary protection measures required.

For more information, please see the WHO plague fact sheet link below:

About 480,000 men, women and children have arrived in Cox’s Bazar since the end of August. Most came with nothing more than the clothes they wore.

Nearly 200 of the women have given birth since they arrived and another 20,000 are pregnant.

The authorities made 22 decisions to remove logistical hurdles. These included building 14 storage warehouses, regulating aid distribution, protecting orphans, building roads and power infrastructure, and setting up shelters for more than 500,000 people.

475 tonnes of aid have arrived at Chittagong airport north of Cox’s Bazar

U.S. Ambassador to the United Nations Nikki Haley on Thursday called on countries to suspend providing weapons to Myanmar over violence against Rohingya Muslims until the military puts sufficient accountability measures in place.

State of the Union 2017 – Commission presents next steps towards a stronger, more effective and fairer EU migration and asylum policy

On 13 September, in his annual State of the Union address, President Jean-Claude Juncker said: “In spite of the debate and controversy around this topic, we have managed to make solid progress (…)We now need to redouble our efforts. Before the end of the month, the Commission will present a new set of proposals with an emphasis on returns, solidarity with Africa and opening legal pathways.”

The Commission is today reviewing progress on the 2015 European Agenda on Migration and setting out the next steps to put in place the missing elements of a stronger, fairer and more effective EU migration and asylum policy. Building on the progress achieved so far, the Commission is today presenting a series of new initiatives in key areas: a new resettlement scheme for at least 50,000 refugees, pilot projects for legal migration which the Commission can help finance and coordinate, and new measures to make the EU’s return policy more effective. The Commission also calls on Member States to urgently make progress on the reform of theCommon European Asylum System and make further efforts to work with countries of origin and transit of migration, in particular by providing additional contributions to the EU Trust Fund for Africa.

First Vice-President Frans Timmermans said: “Our joint efforts to respond to the migration and refugee crisis have led to tangible results, with irregular arrivals significantly down in both the Eastern and the Central Mediterranean. However, we’re not there yet, so we must stay the course and further consolidate our comprehensive migration approach by putting in place the remaining building blocks.”

High Representative/ Vice-President Federica Mogherini said: “Over the last two years, we finally built an EU policy on migration, which is starting to deliver. It is about managing one of the most complex, structural phenomena of our times, not a temporary emergency. Our cooperation with our partners in Africa, but also with the UN, has started to bear fruits by ensuring a better protection of migrants, making traffickers and smugglers’ business less profitable, and offering alternatives and legal avenues. We will keep working on the same track: We’ll only succeed by working in a united and consistent manner.”

Commissioner for Migration, Home Affairs and Citizenship Dimitris Avramopoulos said: “Now is the moment to take the next steps to achieve a fair, robust and realistic EU migration policy. This means continuing to show solidarity with the most affected Member States, but also finding quickly the right compromise on the reform of the Common European Asylum system. It also means improving returns and today we propose to create a true operational EU return hub within the European Border and Coast Guard Agency. And we need to open real alternatives to taking perilous irregular journeys. Investing in more legal pathways, both for protection but also for study or work, is therefore essential. “

The Mid-term review of the European Agenda on Migration shows the positive impact of EU migration management over the past two years on reducing the incentives for irregular migration, strengthening the protection of our external borders, upholding our duty to assist refugees and enhancing legal pathways to Europe. Building on these results, it is now essential to maintain the current efforts, step up the work towards more stable and structural solutions and remain ready to respond to unforeseen situations, as the migratory pressure on Europe remains high. That is why the Commission proposes to take the following next steps:

Continuing to ensure solidarity

With over 29,000 persons relocated so far, the first ever large-scale EU-coordinated relocation mechanism has contributed to significantly reducing the pressure on the asylum systems of Italy and Greece. The immediate priority is now to ensure that all the remaining eligible persons who have arrived to Greece and Italy until September 26 are relocated swiftly. In total, around 37,000 people are expected to be effectively relocated under the scheme.

The migratory pressure on Italy and Greece however continues to remain high, due to the accumulated backlog from the arrivals in 2016 and first half of 2017. The Commission stands ready to provide financial support to Member States who sustain their relocation efforts beyond the current schemes. The assistance provided by EASO and other EU agencies to Italy and Greece should also continue and, when needed, be further reinforced.

At the same time, we cannot continue to rely on ad hoc measures. That is why the Commission calls on the co-legislators to make use of the current window of opportunity and achieve decisive progress on the reform of the Common European Asylum System and especially the Dublin Regulation.

Enhancing legal pathways: at least 50,000 new resettlement places

The Commission is recommending a new EU resettlement scheme to bring at least 50,000 of the most vulnerable persons in need of internatio­nal protection to Europe over the next two years. This is part of the Commission’s efforts to provide viable safe and legal alternatives for those who risk their lives at the hands of criminal smuggling networks. The new scheme will be in place until October 2019 and will build on the current successful resettlement schemes which, having provided new homes to over 23,000 persons in the EU, are now coming to an end.

The Commission has set aside €500 million to support Member States’ resettlement efforts. Whilst resettlement from Turkey and the Middle East must continue, increased focus should be put on resettling vulnerable persons from North Africa and the Horn of Africa; notably Libya, Egypt, Niger, Sudan, Chad and Ethiopia. This will contribute to further stabilising migration flows along the Central Mediterranean route and notably support the UNHCR in establishing an emergency evacuation mechanism from Libya. Today’s recommendation follows up and complements the resettlement pledging exercise launched on 4 July 2017 which has so far resulted in 14,000 pledges by 11 Member States. It will serve to bridge the period until the new permanent EU Resettlement Framework, proposed by the Commission in July 2016, is adopted.

In addition, the Commission encourages Member States to set up private sponsorship schemes allowing private groups or civil society organisations to organise and finance resettlements in accordance with national legislation. To this effect, the Commission has invited EASO to coordinate a pilot project on private sponsorship schemes with interested Member States.

To turn irregular flows into needs-based economic migration to EU Member States, the Commission is proposing to coordinate and financially support pilot projects for legal migration with third countries. They should focus initially on countries which have shown political engagement in finding joint solutions to tackle irregular migration and readmission of irregular migrants. The European Parliament and the Council should also swiftly come to an agreement and adopt the Commission proposal for a revised EU Blue Card which will improve the EU’s ability to attract and re­tain highly skilled workers and ensure that Member States can rely on the work force they need, when they need it.

The EU’s common visa policy is also an essential instrument for mobility, notably facilitating tourism and business, but also a key tool to prevent security risks or risks of irregular migration. The Commission will assess whether the current visa policy still matches present and future challenges, and will reflect on the need to modernise it.

A more effective EU policy on return

With return rates remaining unsatisfactory (around 36% in 2014-2015) and an estimated 1.5 million people to be returned from EU Member States in the near future, the Commission proposes to step up return efforts on all fronts. The Return Department will be significantly reinforced within the European Border and Coast Guard to ensure the Agency can implement a truly proactive return management approach and drive and coordinate the EU-wide management of returns.

Member States need to further streamline their return policies in line with the 2017 Commission Recommendation and the Renewed Action Plan on Returns and in close cooperation with the European Border and Coast Guard Agency. To this effect, the Commission is today publishing a revised Return Handbook that integrates all these recommendations to national authorities on returns. Member States at the external borders can, where appropriate, use the hotspot approach to ensure that return operations can be managed swiftly, in particular in situations of significant arrival surges.

To increase cooperation on readmission by countries of origin, all incentives and leverages available at EU and national level must be applied.

External dimension: Moving forward under the Partnership Framework

Significant results have been achieved in jointly managing migration flows with countries of origin and transit since the establishment of the Partnership Framework for Migration one year ago. While the progress made needs to be sustained, more work is needed on a number of key issues. This includes further strengthening the EU Trust Fund for Africa and in particular its North Africa window through additional Member State funding.

With arrivals and the number of deaths at sea down, the joint work along the Central Mediterranean route needs to be continued. Work which needs to be further stepped up includes improving the situation of stranded migrants in Libya in cooperation with UNHCR and IOM, in particular in detention centres, the promotion of socio-economic opportunities for local communities, stepping up work on assisted voluntary returns and strengthening the capacity of the Libyan authorities to control the southern borders. In addition, work must be continued along other migratory routes, especially in view of the increasing interconnectivity of such routes.

The EU and Member States must also work closely together to achieve an ambitious UN Global Compact for Safe, Orderly and Regular Migration and the development of the Global Compact for Refugees and the Comprehensive Refugee Response Framework with pilot countries.

Background

Upon taking office, European Commission President Jean-Claude Juncker entrusted a Commissioner with special responsibility for Migration, Dimitris Avramopoulos, to work together with the other Commissioners, under the coordination of First Vice-President Frans Timmermans, on a new policy on migration as one of the 10 priorities of the Political Guidelines of the Juncker Commission.

On 13 May 2015, the European Commission proposed a far-reaching strategy, through the European Agenda on Migration, to tackle the immediate challenges of the ongoing crisis, as well as to equip the EU with the tools to better manage migration in the medium and long term, in the areas of irregular migration, borders, asylum and legal migration.

Today’s Communication serves as a mid-term review of what has been achieved so far in delivering the European Agenda on Migration. It also sets out new initiatives from the Commission to address key areas, and identifies where further efforts are needed in the coming months.

Hurricane Maria tore across Puerto Rico on September 20, 2017, ravaging both urban and rural areas with category 4 winds and intense rainfall for several days. Most of the electric power grid and telecommunications network was knocked offline; towns both inland and at the coast were swamped with floodwaters and storm surges; and the lush green landscape turned brown from damaged vegetation and mud and debris deposits.

On September 26, 2017, the Operational Land Imager (OLI) on the Landsat 8 satellite captured some of the first natural-color satellite images of Puerto Rico after Hurricane Maria. Cloud cover is common in the tropics and has been particularly bad in the days since the storm, so researchers have been unable to see much from orbit.

The images above show the Rio Grande de Loíza, the island’s largest river by volume, where it meets the Atlantic Ocean several miles east of San Juan and west of Suárez. The images below show an interior portion of the island around the Lago Loíza reservoir, south of San Juan and north of Caguas. In each pair the second image shows the same area one year ago (September 23, 2016) so as to provide a proper seasonal comparison. (Note: the green color of the lake in 2016 could be an algae bloom or some other form of water vegetation.)

NASA’s Disasters Program has delivered to the Federal Emergency Management Agency (FEMA) a map of areas in eastern Puerto Rico that have likely been damaged as the result of the landfall of Hurricane Maria. The “damage proxy map” was created by the Advanced Rapid Imaging and Analysis team (Jet Propulsion Laboratory) and derived from synthetic aperture radar images from the European Space Agency’s Copernicus Sentinel-1A and Sentinel-1B satellites.

The National Oceanic and Atmospheric Administration is making aerial surveys of the U.S. states and territories affected by hurricanes Harvey, Irma, and Maria. Click here to see photos as they become available.